June 16, 2010 Clinical guidelines recommend screening low-risk women for cervical cancer every three years after age 30, but most primary care clinicians report that they would advise testing for the disease more frequently, according to a report in the June 14 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. Adding a test for human papillomavirus (HPV) to screening protocols does not increase clinicians' reported adherence to guidelines, but may make them less likely to extend screening intervals.
Annual Papanicolaou (Pap) testing has helped decrease the burden of cervical cancer in the United States, according to background information in the article. The U.S. Preventive Services Task Force -- citing evidence that screening annually does not improve outcomes when compared with screening every three years -- has long recommended extending screening intervals up to every three years. Other guidelines, including those of the American Cancer Society (ACS) and American College of Obstetrics and Gynecology (ACOG) traditionally have recommended that women have three annual normal Pap tests before switching to less frequent screening.
Recently, improved understanding of HPV infection and its role in cervical cancer, along with tests for HPV, have resulted in stronger recommendations from ACS and ACOG to extend screening intervals without requiring prior normal Pap tests. "Cost-effectiveness and other studies evaluating HPV co-testing [combining HPV and Pap tests] in the United States and elsewhere have concluded that lengthening screening intervals is a fundamental assumption and advantage of HPV co-testing," the authors write.
Mona Saraiya, M.D., M.P.H., of the Centers for Disease Control and Prevention, Atlanta, and colleagues surveyed 1,212 primary care physicians, of whom 950 performed Pap tests and had ever recommended the HPV test for their patients. The clinicians -- who included general practitioners, family practitioners, obstetrician-gynecologists and general internists -- were asked to report their screening recommendations in response to clinical vignettes.
For a 35-year-old woman with no new sex partners in the past five years and three normal Pap test results, 31.8 percent of clinicians reported they would recommend the next Pap test in three years and 31.7 percent would recommend the next Pap test in one year. However, for a 35-year-old woman with one normal Pap test and a normal HPV test, 19 percent of clinicians would extend the screening interval to three years, whereas 60.1 percent would recommend annual testing.
Cost-effectiveness models "suggest that the practice patterns we found in our study are likely to increase costs with little improvement in reducing cervical cancer incidence and increasing survival. Overuse of screening is expensive for the health care system and may result in unnecessary follow-up testing, increased risk of colposcopy-associated morbidities and adverse birth outcomes and distress for patients," the authors write.
"Many physicians reported overscreening women by using both the HPV and Pap tests annually. Until measures are in place to reinforce extended screening intervals among women with negative HPV and normal Pap test results, there is no advantage gained with HPV co-testing, and it is more expensive."
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- Mona Saraiya; Zahava Berkowitz; K. Robin Yabroff; Louise Wideroff; Sarah Kobrin; Vicki Benard. Cervical Cancer Screening With Both Human Papillomavirus and Papanicolaou Testing vs Papanicolaou Testing Alone: What Screening Intervals Are Physicians Recommending? Arch Intern Med, 2010; 170 (11): 977-986 [link]
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